Random thoughts from a few cantankerous American physicians. All contributors are board certified. Various specialties are represented here. I do not know where this will lead but hope it will at least be an enjoyable read. All of the names mentioned in this blog are pseudonyms, the ages have been changed, and in half the cases the gender as well. All photographs are published with patient consent or are digitally altered to preserve anonymity. Trust us, we're doctors.

Tuesday, August 19, 2008

Now 'cowboy' has connotations within medicine that entail being overly aggressive with patient management or taking silly chances or making wild guesses, but this is not what I mean.

I wanted, within the walls of the ER, to be in charge. I figured that, being Board Certified and subject matter expert would allow me to be benevolent King in the ER. Oh how wrong I was!

The real power in medicine today and the ability to effect meaningful change is not vested in practicing physicians. It is vested in the clipboard carriers... the makers and enforcers of policy and procedure, and the 'owners' of the 'business'.

Example: Three years ago at my current institution the method for performing urinalysis was changed from the simple dipstick method (with dedicated lab confirmation and culture when needed) to the whiz-bang (nice pun eh?), can't miss, lab-run urinalysis.

Besides being a huge waste of money this extended patient stays in the ER for no good reason as the lab UA takes longer.

Add to this an administrative decision that all urinalyses had to be ordered by the nurse in charge of the patient, not the unit clerk (who orders all other labs), and we now find ourselves waiting hours for a urine result. It is often the last thing we get back, even after the CT scans are read and resulted, the blood results are in, the EKG is interpreted, and the disposition is almost made. Often, when I am waiting on a urine, I just cancel it and make an educated guess that the urine is normal OR I go ahead and treat a urinary infection based on clinical presentation.

Simple fix right? Bring back the dipstick UA or have the clerk order them with the other labs or SOMETHING for the sake of humanity!

But no. The answer, from eljefe supremo, the nurse manager and the lab manager, is that it can't be changed because if we did change it back it would cause the earth to stop spinning on its axis and we would all fly off into space.

The people with clipboards have also decided the following...

1. We have enough nurses (we don't).

2. Nurses should be happy to work for less money here than at the place down the street (which is hiring by the way).

3. Good nurses can either like it or lump it... their resignations are accepted the minute they are delivered, but bad nurses, kinda easy to get at our rates and in our busy ER, can not be fired on the spot even for committing errors that a first year nursing student would not make, but must be 'mentored' and, if, after five years or so, they are not firmly part of the team, a 'termination process' must occur which in itself takes five years and must be given the seal of approval of Al Sharpton, Louis Farrakhan, the KuKlux Klan, la Raza, and Hillary Clinton.

4. There are no ICU beds. Ever.

5. We do not need to fully staff the OR... surgeons should be able to operate by themselves, and, in a pinch, perhaps with an anaesthesiologist.

6. We do not need patient transporters... this is a duty best performed by RNs.

7. When we are short-staffed (every day), we are short-staffed. The nurse manager will NOT come in to fill the gap as he is long past his clinical days, and besides, he is in Aruba.

8. Our hospital is a success, just look at the numbers!

9. The understaffing is not a problem because "no one has died yet".

10. Doctors are not good at administration. It's really complicated and best left to the professionals... you know, the folks that have a hospital administration degree or something that looks vaguely like it. Doctors mess things up by insisting on things that aren't needed... you know, like OR nurses.

More brain-busters follow directly related to our subjugation to administrators...

11. TOFKAJCAHO rules! My favorite rule... "there is to be no food in 'patient care areas'." These areas are specifically where patients are not. In other words, there is no food or drink allowed in the nursing or doctor areas, only in the patient's rooms. If followed to the letter, this means that physicians and nurses need to leave the ER to eat or drink. Good idea. They don't really need to be in the ER anyway, they don't need to eat or drink while on the clock, and what's the worst that could happen?

12. EMTALA. Need I say more? If we make a law that everyone has to be given a 'screening exam' and definitive care of 'emergency medical conditions' (whether they can pay or not) the system will not be crushed, doctors and nurses will not quit, and the money to pay for the free care will magically appear. If it does not appear it will be made to appear. Duh.

16. Clipboard Satan decided that REGISTERED FREAKING NURSES, can not administer certain 'dangerous' medications anymore. So what ends up happening when I choose to use, say, propofol for sedation, is that the nurse hands me the syringe full of propofol and I ask them where it hooks up and how much to give to equal the dose I ordered and they end up doing doing it anyway. Or I let them give the medicine while touching them with my index finger on their shoulder thereby taking advantage of the old 'electricity' rule from the game of 'tag'. Then the beleaguered nurse charts that I 'pushed' the medicine. Absolute fucking insanity.

Today's doctors are just like yesterday's. We are professionals with thorough training and skills that are unique. We are, to draw an analogy, like a professional boxer being told, prior to the first punch, that we have to fight blindfolded and with one arm only. Thankfully, one of our national organizations has finally got of its butt and started a petition so that we may do what is right for our patients without the clipboarders interrupting us. You may see it here (Docs, please sign this if you will).

HIPAA, EMTALA, and TOFKAJCAHO could all be trashed if folks on our side would simply follow this rule... DO WHAT'S RIGHT FOR THE PATIENT RIGHT NOW. Of course, this would put a lot of people with clipboards out of "work", but I would happily hold the door for them on their way out.

This is so by far that best web blog on the internet! I always laugh so hard...it truly is good medicine for the soul. The writers of HOUSE just wish they could be so true to life and hiliarious at the same time. Reality is much funnier than fiction. I have been working with the same people you do...I think medical clones have taken over....why didn't they clone Florance Nightingale or Clara Barton or Dr. Web MD....

Am I the only layperson out there reading this brilliant blog? I look at the comments and most of them seem to be other medical professionals ... which is probably a good thing! Lucky me ... knock on wood ... I have never really been sick, not hospital sick, but, if I ever am, how do I find you guys? You may be the last hope. Thank you for your sense of humour, your insight, your thoughts.

No, Kate, I'm totally a lay person...that came out weird, didn't it? My only relationship to docs is that I write about them.

We are professionals with thorough training and skills that are unique. 911, dahlink, you may be a professional, but you don't have the wiring for critical thinking. Geez, didn't the clipboards teach you that?

I luuuuuv you.You forgot--17. Do the best with what you've got. Somehow the daily mantra at my place has not been picked up by PR & Marketing. What's up with that??

In reference to #16. Since that is a State Board of Nursing issue and there have been RN's (5 so far, I believe) in KY that have LOST their license, thus their livelihood...NO RN ANYWHERE at any time would ever, ever, ever give IVP propofol or vecuronium. Ever. The thought does not even enter our silly little brains. The drugs are that dangerous to the practice of frontline/ bedside nursing.

"taking advantage of the old 'electricity' rule from the game of 'tag'"

after how hard you worked to become a doctor in the first place is completely ridiculous. If I trust you messing around on my insides (that wasn't meant to be dirty at all I swear!), then I trust you to take full care of me and decide what needs to be done, when, and how. I can't believe there is anyone that believes they know more than the doctor right there right then. That seems sort of arrogant to me. Rules and such are great, but in something so variable as medicine, most of the rules seem just plain crazy. It is so insane, and arbitrary rules become such a hindrance to you actually taking good care of the patient that it sort of hurts my head to think about how it got to be this way. I am sorry you have to deal with this!

jesus christ.have we lost our minds here?we ( er nurses) get the rsi kit from stat pyxis bin.draw up the meds ( vec included) and repeat the "verbal" * order and push the drug.come on.. this is what we do...gosh.. there is a patient that needs that tube.i like the idea of the doc touching my foot with his/her foot ( as he/she gets stuff ready @ the head of the bed..) and that counts as doc administered.

At what point does complying with JCAHO become so dangerous to the patients that we are ethically obligated to disobey, and do so openly? What if professional organizations representing many different healthcare disciplines issued a joint resolution describing how we can recognize when we have reached that point, and how we will organize mass civil disobedience?

Dear Countryrat, My understanding of some of the problem, Propofol & Vecuronium, is that it is a turf battle with anesthesia & nurse anesthestists wanting to set a boundary about who is able to give certain medications. They have gotten State Boards of Nursing involved with quite severe consequences for many nurses caught in the middle--at the bedside or stretcher-side. Supposedly RNs are able to be tested as competent to give these meds, but unable to move those wheels so far in my part of the universe.

oy. i'm glad to know that i'm not the only lay reader. i'm learning much from this blog and the frustrations of a job which many view as "glam" and often don't see the long hours, the bs paper work and frustrations of suits who don't understand the job running the job.

my hat (well, i don't wear a hat, so a metaphorical one) is off to your profession and to you. er docs have saved my life, just saved my brother's life and are generally the funniest bunch around.

i won't forget an er doc who literally took the time to explain why my shoulder hurt and how to make it through the 10 days until i could see an ortho on a very busy long weekend. he didn't have to do it and god only knows he didn't have the time.

Dear distracted by shiny objects, thank you for that clarification. However, my comment was directed at real JCAHO idiocy, like not allowing ER personnel to keep resuscitation meds in patient care areas, requirements that take clinical staff away from sick patients to perform meaningless, ritualistic documentation, rules against ordering antibiotics until docs jump through unnecessary administrative hoops, and other threats to patient safety. I am not saying that every problem in our hospitals is the fault of JCAHO, Lord knows, we make plenty of them for ourselves, or that every JCAHO regulation is dangerous. Most are not. I am referring narrowly to those regulations that clearly interfere with the ability of providers to care for critically ill and injured patients, and so, threaten the lives of those patients. What is our ethical responsibility in these cases?

PS: I am so jealous of your screen name. It is one of the best I have seen. Can I buy if from you?

Oh Hell Yes!! Will sell for trinkets or baubles...I'm right there with everyone else about the inanity of JCAHO and the crazy fact that the hospitals pay THEM$$$ for their critiques. I really just wanted to point out that RNs can lose their licenses over the propofol IVP regulations and that care should be taken not to jokingly state they are doing something on this permanent cyberspace record to who-knows-who that could cost them their ability to put food on the table and pay the rent. The Board of Nursing does not play nice, so let's none of us go there.

OMG...another hilarious post! As one required to deal with some of the enormous amount of information generated in a patient encounter, I see the results of being required to basically over-document everything done to and for a patient.

And the * as the new symbol idea rocks! JCAHO is merely another symptom of bureaucracy run amok. Too much "playing by the rules" and not enough opportunity to really provide for patients. Maybe it's a good thing I didn't make it to med school after all...I see enough of the insanity as it is, and I think it would have been an endless source of frustration if I'd been trying to practice medicine as I thought it ought to be.

The motto at the hospital that I USED to work for, comes straight from "management"* "If you don't like it here, work somewhere else*"If you point out problems in a staff meeting, or speak your mind about the B.S. that is going on, or point out valid reasons that inhibit your ability to do your job efficiently and safely, you are labeled a trouble maker and the quote above is all you get* Took me a while to figure out the reason why*Department managers and even directors are spineless little puppets with absolutely no authority to do anything including make decisions on their own* Even though the great and powerful OZ hasn't a f*#king clue what goes on in your dept. if it isn't fattening his multi million dollar bonus, it ain't happening, doesn't matter who you are* And to hell with patient care, that is just a fluffy little catch phrase that OZ likes to feed to the media*

911doc..hey it's me, lily!don't i get something.. tofu dinner, whatever??i came up with the * a-hole symbol up there..please?i need some recognition since i just had to sit through some bs meeting about central line insertion and compliance with patient consent forms.yeah.

sorry for the late response. your thanks are appreciated and let me emphasize that it has always been my position that the large majority of physicians went into medicine to care for patients and make a difference in a real way. sure we have our fair share of money-grubbing a-holes, but less, perhaps, than other professions.

actually.. scratch the tofu..vodka sounds much better.. esp. after a few of my non-compliant * charts were audited..those frickin' signatures are soooo hard to get from these patients circling the drain...

Why don't doctors unite? I DON'T KNOW. I POSTED ON THIS UNDER THE TITLE 'GEORGIA O'KEEFE'. I ALSO THINK IT'S NOT IN OUR NATURE... WE ARE DOCTORS, FOR THE MOST PART, BECAUSE WE LIKE TO DO MEDICINE. MOST OF US CAN BARELY SQUEEZE IN A VACATIoN MUCH LESS A MARCH ON WASHINGTON. ALSO, OUR NATIONAL ORGANIZATIONS DO NOT ADVOCATE FOR US VERY WELL. THEY MIGHT NOT LIKE EMTALA BUT NONE OF THEM OPENLY ADVOCATE FOR ITS REPEAL.

Do they not all agree? NO, WE DO NOT ALL AGREE. I THINK THE CURRENT CRISIS IMPACTS HOSPITAL PHYSICIANS PRIMARILY AND THERE ARE PLENTY WHO HAVE PRACTICES THAT ARE SEPARATE FROM THEIR TOWN'S HOSPITAL SO THEY DON'T FEEL THE IMPACT OF EMTALA. AH, DERMATOLOGY! ALSO, THERE ARE QUITE A FEW PHYSICIANS WITH LEFTIST LEANINGS BUT THEY DO TEND TO LIVE IN AREAS THAT SERVE PREDOMINANTLY WEALTHY PATIENTS AND THEREFORE MAKE GOOD MONEY. ALSO, THERE ARE PLENTY OF 'TRUE BELIEVERS' WHO WORK AT HEALTH CLINICS FOR LOW PAY AND ARE QUITE HAPPY. MY ONLY QUIBBLE WITH THE LATTER IS A PHILOSOPHICAL ONE BUT I SAY 'GOD BLESS 'EM".

Are the truly powerless? WE ARE NOT POWERLESS BUT WE BELIEVE WE ARE, AND WITH HUNDREDS OF THOUSANDS OF DOLLARS OF DEBT OUT OF RESIDENCY IT'S A BRAVE YOUNG DOC WHO WILL LAY IT ON THE LINE.

Or is it all just too big and everyone is just trying to make there way? THIS IS SAD BUT TRUE FOR MOST DOCS.

You can't eat an elephant all at once...but you can eat him one bite at a time. :) I'M READY FOR A FEAST.

I heard once at a conference(and coming from a doc) that uniting doctors is very similiar to herding cats. feral cats. Makes me laugh!Thought this might make you laugh...heard today from one of our "Quality Control" RNs who has to check the documentation (and HATES JCAHO)that our State Board of Nursing has come out with a new regulation(equals law) that our signatures must be legible in all and any charting 100% of the time--like when I'm transfusing those 14 units of blood in one hour for my little GI bleed guy. They have a hotline where an RN can be reported for illegible signatures. I kid you not. I think we should be reported to a hotline for LOOKING hot, or where to see hot nurses. The world as we know it has gone completely nuts.

Seaspray: I am not an expert, and I do not claim to know all of the answers to your very astute question, but I think that I can explain one part of the reason why doctors, nurses, techs, et al are loosing control of healthcare. It is not the only reason. It is probably not the most important reason. However, it is part of the problem, and something I have never heard mentioned, except by me. So, for what it is worth, here goes:

There is a fundamental contradiction between the culture of medicine and the culture of administration and law (hereafter referred to as forensics). In medicine, we see the world as an objective reality that is the way it is because of immutable natural laws. If I give my hypotensive patient intravenous dopamine in a certain concentration, at a certain rate, and his serum pH is not too low, and he has adequate volume and ejection fraction, and there is nothing preventing the binding of the drug at the target receptors, his blood pressure WILL increase. No negotiation. No authority to appeal to. No legal contest. No discussion of how some special interest group feels about it. That is just how the physical chemistry of dopamine interacts with mammalian physiology. Period. That is a snapshot of my world (nursing).

The forensic world is very different. In the forensic world, things are true because an entity with jurisdiction over that aspect of life has said so. When the entity changes (through attrition, negotiation, persuasion, compromise, bribery, intimidation, or whatever) then the truth changes with it. To those of us with scientific backgrounds, this is silly and trivial. And, it is how human institutions (like hospitals) are run. Consequently, we medical types are locked in eternal conflict with the forensic types: administrators, lawyers, TOFKAJCAHO, the whole wretched lot of them. Because we have different cultural foundations, we rarely communicate effectively with each other. Each side knows that its position is sensible, and the other groups’ is ridiculous. In fact, neither is ridiculous and neither is sensible. They are just different because they arise from a different set of beliefs about what constitutes the real world.

For centuries, it did not matter much because medical types did medicine and forensic types did administration and law. Now, however, we have medicine beholden to mulyiple administrative entities, and to government and the results are disastrous and getting worse. This is why all the talk about healthcare reform is so futile; because it does not resolve the irresolvable cultural conflict between the players. The solution is to return healthcare to the healthcare providers. However, we live in a time of profound distrust of authority figures. (Wow! We made it full circle to the original topic of paternalism, didn’t we!) And so, because a lot people do not trust the medical experts who know how to provide the care that is needed, we will get more and more administrative, legal, and governmental incursions into medicine (all in the name of “fixing the broken system”), worse care, and lots of otherwise smart people who never figure out that they are sending medicine straight to Hell even as they do what they think will save it.

I'm an OR nurse and I can't figure out... are you for us or against us? We too would like the process to hurry up. I've waited countless hours to do cases because of the ER's inability to transfer the patient.

My clipboard wrote me up for using @ v.s. spelling at in my nursing order. JCAHO doesn't approve the use of @ or bid, tid, po, qd, ac, pc, ou, od,qod,andanything apothecaries is totally out.I DON'T KNOW HOW TO WRITE REGULAR! Ms Clipboad knows where she can put it @.